Fatigue resident survival guide: Difference between revisions

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{{familytree | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 |F01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑  
{{familytree | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 |F01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑  
  [[Heart failure|Congective heart failure]] <br>❑ [[Atypical angina]] <ref name="pmid17631047">{{cite journal| author=Smith OR, Michielsen HJ, Pelle AJ, Schiffer AA, Winter JB, Denollet J| title=Symptoms of fatigue in chronic heart failure patients: clinical and psychological predictors. | journal=Eur J Heart Fail | year= 2007 | volume= 9 | issue= 9 | pages= 922-7 | pmid=17631047 | doi=10.1016/j.ejheart.2007.05.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17631047  }} </ref>|F02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑  
  [[Heart failure|Congective heart failure]] <br>❑ [[Atypical angina]] <ref name="pmid17631047">{{cite journal| author=Smith OR, Michielsen HJ, Pelle AJ, Schiffer AA, Winter JB, Denollet J| title=Symptoms of fatigue in chronic heart failure patients: clinical and psychological predictors. | journal=Eur J Heart Fail | year= 2007 | volume= 9 | issue= 9 | pages= 922-7 | pmid=17631047 | doi=10.1016/j.ejheart.2007.05.016 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17631047  }} </ref>|F02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑  
  [[Chronic obstructive pulmonary disease]] <ref name="pmid14706002">{{cite journal| author=Theander K, Unosson M| title=Fatigue in patients with chronic obstructive pulmonary disease. | journal=J Adv Nurs | year= 2004 | volume= 45 | issue= 2 | pages= 172-7 | pmid=14706002 | doi=10.1046/j.1365-2648.2003.02878.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14706002  }} </ref> <br>❑ [[Sleep apnea]]<ref name="pmid10720054">{{cite journal| author=Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM | display-authors=etal| title=Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. | journal=J Clin Endocrinol Metab | year= 2000 | volume= 85 | issue= 3 | pages= 1151-8 | pmid=10720054 | doi=10.1210/jcem.85.3.6484 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10720054  }} </ref>|F03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Hypothyroidism]] <ref name="pmid22989469">{{cite journal| author=Louwerens M, Appelhof BC, Verloop H, Medici M, Peeters RP, Visser TJ | display-authors=etal| title=Fatigue and fatigue-related symptoms in patients treated for different causes of hypothyroidism. | journal=Eur J Endocrinol | year= 2012 | volume= 167 | issue= 6 | pages= 809-15 | pmid=22989469 | doi=10.1530/EJE-12-0501 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22989469  }} </ref> <br>❑ [[Hyperthyroidism]]<ref name="pmid20656620">{{cite journal| author=Kaltsas G, Vgontzas A, Chrousos G| title=Fatigue, endocrinopathies, and metabolic disorders. | journal=PM R | year= 2010 | volume= 2 | issue= 5 | pages= 393-8 | pmid=20656620 | doi=10.1016/j.pmrj.2010.04.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20656620  }} </ref> <br>❑ [[Chronic renal disease]] <ref name="pmid24335380">{{cite journal| author=Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N | display-authors=etal| title=Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue? | journal=Am J Nephrol | year= 2013 | volume= 38 | issue= 6 | pages= 489-95 | pmid=24335380 | doi=10.1159/000356939 | pmc=3925636 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24335380  }} </ref> <br>❑ [[Chronic hepatic disease]] <br>❑ [[Adrenal insufficiency]] <br>❑ [[Hyponatremia]] <br>❑ [[Hypercalcemia]]|F04=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Anemia]] <br>❑ [[Occult malignancy]]|F05=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Infectious mononucleosis|Mononucleosis syndrome]] <br>❑ [[Viral hepatitis]] <br>❑ [[HIV infection]]<ref name="pmid25077353">{{cite journal| author=| title=Retraction notice to “Differential impact of diabetes and hypertension in the brain: adverse effects in grey matter” [Neurobiol. Dis., 44 (2011) 161–173, http://dx.doi.org/10.1016/ j.nbd.2011.06.005]. | journal=Neurobiol Dis | year= 2014 | volume= 68 | issue=  | pages= 229 | pmid=25077353 | doi=10.1016/j.nbd.2014.05.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25077353  }} </ref> <br>❑ [[Subacute bacterial endocarditis]] <br>❑ [[Tuberculosis]]|F06=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Fibromyalgia]] <br>❑ [[Polymyalgia rheumatica]]|F07=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br>❑ [[Depression]] <br>❑ [[Anxiety|Anxiety disorder]]<br>❑  [[Somatization disorder]] </div>}}
  [[Chronic obstructive pulmonary disease]] <ref name="pmid14706002">{{cite journal| author=Theander K, Unosson M| title=Fatigue in patients with chronic obstructive pulmonary disease. | journal=J Adv Nurs | year= 2004 | volume= 45 | issue= 2 | pages= 172-7 | pmid=14706002 | doi=10.1046/j.1365-2648.2003.02878.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14706002  }} </ref> <br>❑ [[Sleep apnea]] <ref name="pmid10720054">{{cite journal| author=Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM | display-authors=etal| title=Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. | journal=J Clin Endocrinol Metab | year= 2000 | volume= 85 | issue= 3 | pages= 1151-8 | pmid=10720054 | doi=10.1210/jcem.85.3.6484 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10720054  }} </ref>|F03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Hypothyroidism]] <ref name="pmid22989469">{{cite journal| author=Louwerens M, Appelhof BC, Verloop H, Medici M, Peeters RP, Visser TJ | display-authors=etal| title=Fatigue and fatigue-related symptoms in patients treated for different causes of hypothyroidism. | journal=Eur J Endocrinol | year= 2012 | volume= 167 | issue= 6 | pages= 809-15 | pmid=22989469 | doi=10.1530/EJE-12-0501 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22989469  }} </ref> <br>❑ [[Hyperthyroidism]] <ref name="pmid20656620">{{cite journal| author=Kaltsas G, Vgontzas A, Chrousos G| title=Fatigue, endocrinopathies, and metabolic disorders. | journal=PM R | year= 2010 | volume= 2 | issue= 5 | pages= 393-8 | pmid=20656620 | doi=10.1016/j.pmrj.2010.04.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20656620  }} </ref> <br>❑ [[Chronic renal disease]] <ref name="pmid24335380">{{cite journal| author=Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N | display-authors=etal| title=Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue? | journal=Am J Nephrol | year= 2013 | volume= 38 | issue= 6 | pages= 489-95 | pmid=24335380 | doi=10.1159/000356939 | pmc=3925636 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24335380  }} </ref> <br>❑ [[Chronic hepatic disease]] <ref name="pmid11164055">{{cite journal| author=Dwight MM, Kowdley KV, Russo JE, Ciechanowski PS, Larson AM, Katon WJ| title=Depression, fatigue, and functional disability in patients with chronic hepatitis C. | journal=J Psychosom Res | year= 2000 | volume= 49 | issue= 5 | pages= 311-7 | pmid=11164055 | doi=10.1016/s0022-3999(00)00155-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11164055  }} </ref> <br>❑ [[Adrenal insufficiency]] <ref name="pmid30383218">{{cite journal| author=Colombo C, De Leo S, Di Stefano M, Vannucchi G, Persani L, Fugazzola L| title=Primary Adrenal Insufficiency During Lenvatinib or Vandetanib and Improvement of Fatigue After Cortisone Acetate Therapy. | journal=J Clin Endocrinol Metab | year= 2019 | volume= 104 | issue= 3 | pages= 779-784 | pmid=30383218 | doi=10.1210/jc.2018-01836 | pmc=6402317 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30383218  }} </ref> <br>❑ [[Hyponatremia]] <br>❑ [[Hypercalcemia]]|F04=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Anemia]] <br>❑ [[Occult malignancy]]|F05=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Infectious mononucleosis|Mononucleosis syndrome]] <br>❑ [[Viral hepatitis]] <br>❑ [[HIV infection]]<ref name="pmid25077353">{{cite journal| author=| title=Retraction notice to “Differential impact of diabetes and hypertension in the brain: adverse effects in grey matter” [Neurobiol. Dis., 44 (2011) 161–173, http://dx.doi.org/10.1016/ j.nbd.2011.06.005]. | journal=Neurobiol Dis | year= 2014 | volume= 68 | issue=  | pages= 229 | pmid=25077353 | doi=10.1016/j.nbd.2014.05.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25077353  }} </ref> <br>❑ [[Subacute bacterial endocarditis]] <br>❑ [[Tuberculosis]]|F06=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br> ❑ [[Fibromyalgia]] <br>❑ [[Polymyalgia rheumatica]]|F07=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Consider differential diagnosis:'''<br>❑ [[Depression]] <br>❑ [[Anxiety|Anxiety disorder]]<br>❑  [[Somatization disorder]] </div>}}
{{Family tree/end}}
{{Family tree/end}}



Revision as of 13:20, 11 August 2020

Fatigue
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mounika Lakhmalla, MBBS[2]Tayyaba Ali, M.D.[3]

Synonyms and keywords:: Weakness, Tiredness, Lethargy, Debility

Overview

Fatigue is a common nonspecific symptom due to a wide range of etiologies.Patients often use this term to describe a range of issues like difficulty initiating activity ; decreased capacity to maintain activity ; Trouble with concentration, memory, and emotional stability; or sleepiness or an uncontrollable need to sleep. The term fatigue can sometimes be used synonymously with Tiredness. Fatigue can present alone as a primary symptom or in association with other localizing symptoms.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

  • Multiple sclerosis[3]
  • After malignancy treatment, patients can experience different patterns of fatigue from chemotherapy, radiation treatment, or surgery[4].

Diagnosis

The approach to diagnosis of fatigue is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of fatigue.

  • Diagnostic evaluation of fatigue when it presents as a predominant symptom includes a detailed history and physical examination, basic laboratory studies, and updated cancer screening interventions.
  • Additional diagnostic testing depends on associated localized findings.
  • Extensive laboratory studies with out a suggestive history or physical exam findings is of limited diagnostic utility while evaluating chronic fatigue[5][6].


 
 
 
 
 
 
 
 
 
 
 
 
Seek proper history, ask patients to describe in their own words, what do they mean by fatigue?
This will help distinguish fatigue from
somnolence
muscle weakness
The history should also determine the characteristics, severity, and temporal pattern of fatigue:
❑ Onset – Abrupt or gradual, relationship to illness or life event
❑ Course – Stable, improving, or worsening
❑ Duration and daily pattern
❑ Factors that alleviate or exacerbate it
❑ Impact on daily life – Ability to work, socialize, participate in family activities
❑ Accommodations that the patient/family has had to make to deal with symptom
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the cardiac symptoms:
Dyspnea on exertion
Orthopnea
❑ Leg swelling
 
Characterize the pulmonary symptoms:
❑ Dyspnea
❑ Chronic cough
❑ Sputum production
❑ Snoring
❑ Interrupted breathing during sleep
 
Characterize the endocrinologic / metabolic symptoms:
Cold intolerance
Weight gain
Constipation
❑ Dry skin
Heat intolerance
Weight loss
❑ Diarrhea
❑ Moist skin
❑ Nausea/vomiting
❑ Mental status changes
❑ Decreased urine
❑ Abdominal distention
❑ Gastrointestinal bleeding
❑ Salt craving
❑ Gastrointestinal complaints
❑ Malaise
❑ Cognitive dysfunction
Anorexia
Polydipsia/polyuria
 
Characterize the hematologic / neoplastic symptoms:
❑ Dizziness
❑ Weakness
Palpitations
Dyspnea
❑ Weight loss
 
Characterize the Infectious diseases symptoms:
❑ Fever/chills
❑ Sore throat
❑ Tender lymph nodes
❑ Nausea/vomiting
❑ Abdominal discomfort
Weight loss
Night sweats
❑ Myalgias
 
Characterize the rheumatologic symptoms:
❑ Chronic diffuse muscle pain
❑ Aching/morning stiffness of shoulders, neck, and hips
 
Characterize the psychological symptoms:
❑ Sad mood
Anhedonia
❑ Altered sleep
❑ Cognitive dysfunction
❑ Generalized nervousness
Panic attacks
Phobias
❑ Multiple chronic constitutional and localized complaints
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Elevated jugular venous distension
❑ Peripheral edema
❑ S3 gallop
❑ Inspiratory rales
 
Examine the patient:
❑ Evidence of hyperinflation
Wheezing
Rales
Obesity
❑ Hypertension
 
Examine the patient:
Bradycardia
Goiter
❑ Slow deep tendon reflex relaxation phase
Tachycardia
❑ Ophthalmopathy
❑ Hypertension
❑ Peripheral edema
Jaundice
Palmar erythema
Gynecomastia
Splenomegaly
❑ Evidence of ascites
❑ Hypotension
❑ Hyperpigmentation
❑ Vitiligo
 
Examine the patient:
Tachycardia
Pallor
 
Examine the patient:
Fever
❑ Exudate pharyngitis
❑ Tender cervical adenopathy
Jaundice
❑ Tender hepatomegaly
❑ New (regurgitant) murmur
Cough
Chest pain
❑ Dyspnea
Hemoptysis
 
Examine the patient:
❑ Multiple "tender points" on palpation
❑ Decreased range of motion of shoulders, neck, and hips
 
Examine the patient:
❑ Tachycardia
❑ Muscle tension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic work-up:
❑ Chest radiograph
❑ Echocardiogram
 
Diagnostic work-up:
❑ Chest radiograph
❑ Sleep study
 
Diagnostic work-up:
Thyroid function tests
Renal function tests/ serum electrolytes
Hepatic function tests
❑ Morning cortisol/ACTH, ACTH stimulation test
❑Serum sodium level
❑Serum calcium level
 
Diagnostic work-up:
Complete blood count
 
Diagnostic work-up:
❑ Complete blood/differential count
❑ Monospot
Hepatic function tests
❑ Viral hepatitis serologies
HIV serology
❑ Blood cultures
Echocardiogram
❑ PPD/gamma-interferon assay
❑ Chest radiograph
 
Diagnostic work-up:
Erythrocyte sedimentation rate
 
Diagnostic work-up:
❑ Screening tests (eg, PHQ-2, PHQ-9, GAD-7, SSS-8
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider differential diagnosis:
Congective heart failure
Atypical angina [7]
 
Consider differential diagnosis:
Chronic obstructive pulmonary disease [8]
Sleep apnea [9]
 
 
Consider differential diagnosis:
Anemia
Occult malignancy
 
 
Consider differential diagnosis:
Fibromyalgia
Polymyalgia rheumatica
 
Consider differential diagnosis:
Depression
Anxiety disorder
Somatization disorder

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  1. Grimstad T, Norheim KB (2016). "Fatigue in inflammatory bowel disease". Tidsskr Nor Laegeforen. 136 (20): 1721–1724. doi:10.4045/tidsskr.16.0134. PMID 27830906.
  2. Swain MG, Jones DEJ (2019). "Fatigue in chronic liver disease: New insights and therapeutic approaches". Liver Int. 39 (1): 6–19. doi:10.1111/liv.13919. PMID 29935104.
  3. Akcali A, Zengin F, Aksoy SN, Zengin O (2017). "Fatigue in Multiple Sclerosis: Is it related to cytokines and hypothalamic-pituitary-adrenal axis?". Mult Scler Relat Disord. 15: 37–41. doi:10.1016/j.msard.2017.03.004. PMID 28641771.
  4. Greenberg DB (2002). "Clinical Dimensions of Fatigue". Prim Care Companion J Clin Psychiatry. 4 (3): 90–93. doi:10.4088/pcc.v04n0301. PMC 181235. PMID 15014735.
  5. Ridsdale L, Evans A, Jerrett W, Mandalia S, Osler K, Vora H (1993). "Patients with fatigue in general practice: a prospective study". BMJ. 307 (6896): 103–6. doi:10.1136/bmj.307.6896.103. PMC 1693499. PMID 8343705.
  6. Lane TJ, Matthews DA, Manu P (1990). "The low yield of physical examinations and laboratory investigations of patients with chronic fatigue". Am J Med Sci. 299 (5): 313–8. doi:10.1097/00000441-199005000-00005. PMID 2337122.
  7. Smith OR, Michielsen HJ, Pelle AJ, Schiffer AA, Winter JB, Denollet J (2007). "Symptoms of fatigue in chronic heart failure patients: clinical and psychological predictors". Eur J Heart Fail. 9 (9): 922–7. doi:10.1016/j.ejheart.2007.05.016. PMID 17631047.
  8. Theander K, Unosson M (2004). "Fatigue in patients with chronic obstructive pulmonary disease". J Adv Nurs. 45 (2): 172–7. doi:10.1046/j.1365-2648.2003.02878.x. PMID 14706002.
  9. Vgontzas AN, Papanicolaou DA, Bixler EO, Hopper K, Lotsikas A, Lin HM; et al. (2000). "Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia". J Clin Endocrinol Metab. 85 (3): 1151–8. doi:10.1210/jcem.85.3.6484. PMID 10720054.
  10. Louwerens M, Appelhof BC, Verloop H, Medici M, Peeters RP, Visser TJ; et al. (2012). "Fatigue and fatigue-related symptoms in patients treated for different causes of hypothyroidism". Eur J Endocrinol. 167 (6): 809–15. doi:10.1530/EJE-12-0501. PMID 22989469.
  11. Kaltsas G, Vgontzas A, Chrousos G (2010). "Fatigue, endocrinopathies, and metabolic disorders". PM R. 2 (5): 393–8. doi:10.1016/j.pmrj.2010.04.011. PMID 20656620.
  12. Jhamb M, Liang K, Yabes J, Steel JL, Dew MA, Shah N; et al. (2013). "Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue?". Am J Nephrol. 38 (6): 489–95. doi:10.1159/000356939. PMC 3925636. PMID 24335380.
  13. Dwight MM, Kowdley KV, Russo JE, Ciechanowski PS, Larson AM, Katon WJ (2000). "Depression, fatigue, and functional disability in patients with chronic hepatitis C." J Psychosom Res. 49 (5): 311–7. doi:10.1016/s0022-3999(00)00155-0. PMID 11164055.
  14. Colombo C, De Leo S, Di Stefano M, Vannucchi G, Persani L, Fugazzola L (2019). "Primary Adrenal Insufficiency During Lenvatinib or Vandetanib and Improvement of Fatigue After Cortisone Acetate Therapy". J Clin Endocrinol Metab. 104 (3): 779–784. doi:10.1210/jc.2018-01836. PMC 6402317. PMID 30383218.
  15. "Retraction notice to "Differential impact of diabetes and hypertension in the brain: adverse effects in grey matter" [Neurobiol. Dis., 44 (2011) 161–173, http://dx.doi.org/10.1016/ j.nbd.2011.06.005]". Neurobiol Dis. 68: 229. 2014. doi:10.1016/j.nbd.2014.05.006. PMID 25077353. External link in |title= (help)


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References